Position statement on nurses and cosmetic medical procedures

Professional Codes & Guidelines

Updated June 2023

Download a PDF of this Position statement: Nurses and cosmetic medical procedures (350 KB)

Introduction

The Nursing and Midwifery Board of Australia (NMBA) has approved registration standards, codes, guidelines and standards for practice that together form a Professional Practice Framework (PPF). The PPF determines the requirements and expectations which guide the professional practice of nurses and midwives in Australia.

The Australian Health Practitioner Regulation Agency (Ahpra) and the National Boards have developed information and resources for consumers and registered health practitioners about expected standards when it comes to cosmetic procedures and can be found in publications on the Ahpra website.

This statement captures the NMBA’s position on nurses working in the area of cosmetic medical and surgical procedures. The main focus of this position statement is minor (non-surgical) cosmetic medical procedures (‘cosmetic medical procedures’). Nurses practising in the area of major cosmetic medical and surgical procedures (‘cosmetic surgery’) work with a medical practitioner.

It is not within a midwife’s therapeutic model of care to work in the area of cosmetic medical procedures.

This position statement includes the following:

NMBA general statements on all nurses working in the area of cosmetic medical procedures, the role of nurses working in this area and important connections to the NMBA’s and other relevant guidance documents
Cosmetic injections – detailed expectations of prescribers and the role of the registered nurse (RN).
Cosmetic medical procedures:
1. RNs and cosmetic medical procedures
2. Enrolled nurses (ENs) and cosmetic medical procedures
  1. ENs currently working in the area of cosmetic medical procedures
  2. ENs planning to work in the area of cosmetic medical procedures in the future
  3. Supervision requirements of ENs
3. Nurse practitioners (NPs) and cosmetic medical procedures
RNs with a sole qualification in mental health nursing, paediatric nursing or disability nursing - seeking to practise in the area of cosmetic medical procedures

1. Nurses working in the area of cosmetic medical procedures

The NMBA recognises that nurses (ENs, RNs and NPs) obtain and develop qualifications and expertise through the course of their careers. It is an expectation that nurses are educated and competent in their specific area of practice and hold the requisite skills required to meet the needs of their client group. The public has an expectation that nurses provide safe, person-centred and evidence-based care in all areas of nursing practice; this includes in the area of cosmetic medical procedures.

Nurses are responsible for making professional judgements about when an activity is within their scope of practice and, when it is not, for initiating consultation and collaboration with, or referral to, other members of the healthcare team.

The NMBA’s standards, codes and guidelines set the regulatory requirements within which nurses working in the area of cosmetic medical procedures must comply, to ensure ongoing competence and safe practice. This includes but is not limited to:

Nurses working in the area of cosmetic medical procedures must know and comply with organisational requirements and relevant state, territory and Commonwealth requirements as jurisdictional differences are common. This includes:

drugs and poisons legislation (however titled) regarding possessing, using, obtaining, selling, storing, prescribing, administering and supplying scheduled medicines. This includes Botulinum toxin type A (commonly called Botox) and dermal fillers.
for the preparation and administration of platelet enriched plasma and other blood products
infection prevention and control, including for procedures such as microdermabrasion and those that involve skin penetration (such as cosmetic tattooing, skin needling and threads)
organisational policies, protocols and guidelines.
completing a recognised laser safety certification and other state or territory requirement/s before performing any laser or IPL treatment¹

Nurses working in the area of cosmetic medical procedures should be aware of the Medical Board of Australia’s (MBA) Guidelines for registered medical practitioners who perform cosmetic medical and surgical procedures (MBA guidelines). These guidelines establish the MBA's expectations of medical practitioners who perform cosmetic medical and surgical procedures. The guidelines serve as an evidence-based framework for nurses, outlining the conduct and practice expectations required of medical practitioners providing cosmetic procedures, and the impact this may have on nurses' practice.

The Therapeutic Goods Administration (TGA) regulates medicines and products that are marketed for therapeutic used. Nurses must comply with TGA requirements by ensuring that the products they administer are registered and approved for the intended use. Administering and/or advertising unapproved and/or unregistered products is unlawful².

Ahpra and National Boards have published a fact sheet Supporting a safe choice about cosmetic injectables. The fact sheet provides information aimed at consumers on what they need to think about before deciding on a cosmetic procedure. The fact sheet identifies what ‘good practice’ looks like in the practice area of cosmetic medical procedures.

Employers must be aware of the scope of practice of all nurses they employ and must ensure there are sufficient resources to enable safe and competent care for the people for whom healthcare services are provided. This includes policies and practices that support the development of nursing practice within a risk management framework and that all policies and practices must be compliant with regulatory and legislative requirements. The National safety and quality primary and community healthcare standards outline the expectations for clinical governance, partnering with consumers and clinical safety for primary and community healthcare settings.

2. Cosmetic injections

Prescribing cosmetic injections

NPs are authorised to prescribe medicines in accordance with state and territory legislation and their context of practice. At all times, the prescribing practice of NPs must be supported by their education, skills and knowledge. This underpins the assessment of, or consultation with, the person receiving cosmetic injections. NPs must not prescribe Schedule 4 cosmetic injections unless they have a consultation with the person receiving the cosmetic injection either in person or via video conferencing. Remote prescribing of cosmetic injections by phone or email (or equivalent) is not acceptable.

The requirements for medical practitioners are set out in the MBA guidelines and mirror the above.

RNs and ENs cannot prescribe Schedule 4 cosmetic injections.

Administering cosmetic injections

The NMBA considers that the administration of cosmetic injections is within the scope of appropriately educated RNs. It requires a detailed assessment and planning of care, complex anatomical and physiology knowledge as well as decision-making relating to pharmacodynamics and pharmacokinetics.

RNs performing cosmetic injections must ensure safe and appropriate administration in accordance with best practice and clinical governance frameworks. The nurse administering the cosmetic injection is responsible for ensuring the person receiving the cosmetic injections receives appropriate post-procedural care. These arrangements should be in place in advance of any treatments and made known to other treating practitioners and the relevant clinical setting where the administering of cosmetic injections occurs.

All nurses must ensure that their practice complies with state and territory legislation related to supply and possession of medicines. There must be an individual medication order for each person receiving cosmetic injections.

The person receiving the cosmetic injections:

must have a consultation and assessment with a medical practitioner or NP, who is located in Australia, in line with the above
is only treated by nurses with the appropriate education, skills and knowledge, utilising up-to-date knowledge of regional anatomy and safest practice
is in a clinical setting that meets acceptable healthcare quality and safety standards, and
is aware of arrangements in place to receive post procedural care

3. Cosmetic medical procedures

a. Registered nurses (RNs) and cosmetic medical procedures

RNs determine, coordinate and provide safe, quality nursing care. RN practice requires critical continuous thinking and analysis and the need to continue to develop professionally. RNs are responsible and accountable for the supervision and delegation of nursing activities to ENs and other healthcare workers.

RNs working in or planning to work in the area of cosmetic medical procedures must ensure that they have the required education, skills and experience to practise safely. RNs that are intending to progress towards endorsement as a NP working solely in the area of cosmetic medical procedures are unlikely to meet the requirements for endorsement as an NP, as the NMBA considers that practising in the area of cosmetic medical procedures, such as cosmetic injecting, is not working at the advanced practice level (in line with the definition provided).

Advanced practice in nursing is demonstrated by a level of practice and is not by a job title or level of remuneration, or a set of procedural skills. Owning and running a health and/or nursing related business for example is not by itself an indication of advanced practice.

b. Enrolled nurses (ENs) and cosmetic medical procedures

The foundational education entry requirement for ENs is not at a level that adequately prepares an EN for the risk and complexities associated with cosmetic medical procedures including the administration of cosmetic injections.

i. ENs currently working in the area of cosmetic medical procedures

The NMBA expects that an EN currently working in this context of practice:

is directly, or has been directly, supervised and assessed by an RN for a minimum period of 75 hours for cosmetic injections, until competence is demonstrated and documented
does not undertake the administration of dermal filler injectables to very high-risk areas³; that includes the glabella, nose and forehead
only undertakes the administration of dermal filler injectables to high-risk areas, including temples, nasolabial folds, peri-orbital and medial cheek, in a clinical setting with immediate access to a medical practitioner, nurse practitioner or an RN
only performs laser skin resurfacing with direct supervision of an RN to check the laser settings before use
engages in continuing professional and skills development relevant to this context of practice.

Recency of practice

If an EN ceases employment in the area of cosmetic medical procedures and later seeks to return to the area of cosmetic medical procedures, the EN must meet the requirements of the NMBA's Registration standard: Recency of practice (RoP). That is, that they have practised in the area of cosmetic medical procedures for a minimum of 450 hours in the past five years.

Where an EN has ceased practising in the area of cosmetic medical procedures and does not meet the RoP requirements, they must then fulfill the entry requirements outlined in point ii below.

ii.ENs planning to practise in area of cosmetic medical procedures in the future

ENs intending to practise in the area of cosmetic medical procedures in the future, in addition to the expectations above, are required to demonstrate the following experience and education requirements:

practise for a minimum of one-year full-time equivalent post initial registration to consolidate the foundational skills and knowledge of an EN, plus
two years’ full-time equivalent experience in a related area of practice (for example dermatology, general surgery) prior to practising in the area of cosmetic medical procedures, and
completed formal education that is relevant to the practice in the area of cosmetic medical procedures practice.

Should a notification be lodged relating to a nurse’s practise in the area of cosmetic medical procedures, the nurse will be asked to demonstrate how they meet the NMBA requirements outlined in this position statement.

iii. EN supervision requirements

ENs must work under the direct or indirect supervision of an RN, as required in the NMBA Enrolled nurse standards for practice and the Fact sheet: Enrolled nurse standards for practice. This is a fundamental requirement that applies to the practice of all ENs. Supervision by a health practitioner other than an RN − a GP or another medical practitioner for example − does not meet the NMBA’s supervisory requirement.

Direct supervision is where the RN is physically present and personally observes, works with and directs the EN. This may be necessary for example, to determine an EN’s competence against the standards for practice.

Indirect supervision is where the RN works in the same state or territory-based organisation, is readily available but does not constantly observe the EN's activities. It is generally expected that in the case of indirect supervision that the RN and the EN have the same employer.

There may be situations where the RN and the EN may not have the same employer but work in the same facility or organisation. In these situations, clearly documented arrangements between the employers, supported by the RN/s and the EN, must be in place. These documented arrangements should include details of all aspects of the supervision arrangements (including insurance) and describe how the RN will be available for reasonable access to ensure effective timely direction and supervision so that the delegated practice is safe and correct and public safety is ensured.⁴

The NMBA’s Decision-making framework for nursing and midwifery provides direction on decision-making relating to scope of practice and delegation.
Employers are accountable for ensuring the appropriate supervision of ENs. The need for an EN to have supervision arrangements in place with a named and accessible RN at all times and in all contexts of care for support and guidance is critical to patient safety.

c. NPs and cosmetic medical procedures

NPs practise in a generalist or specialist advanced practice level that incorporates professional leadership, education, research and support of systems into their nursing practice. Their practice includes relevant expertise, critical thinking, complex decision-making, autonomous practice and is effective and safe. It reflects the practice of nurses who are responsible and accountable in managing people who have complex healthcare requirements.

NPs are educated and authorised to prescribe and administer scheduled medicines and order diagnostic investigations. NPs must work in accordance with the relevant state, territory and Commonwealth drugs and poisons legislation, organisational policy as well as Commonwealth legislation regulating blood products and medical devices.

At annual registration renewal, NPs are required to declare that they have met the minimum practice requirements of the Registration standard: Recency of practice, at an advanced level, have met and comply with the NMBA Nurse practitioner standards for practice and have direct clinical contact relevant to their endorsement.

4. Registered nurses with a sole qualification in mental health nursing, paediatric nursing or disability nursing – seeking to practise in the area of cosmetic medical procedures

RNs with a notation that states ‘solely qualified in the area of mental health, paediatric or disability nursing’ are unable to practice in the area of cosmetic medical procedures. If RNs with this notation want to change their context of practice to work in the area of cosmetic medical procedures, they must complete an NMBA-approved entry to practice program of study leading to general registration in order to have the notation removed. They also need to ensure that they have the appropriate education and experience to work in a different context of practice. Additional information can be found in the Fact sheet: Nurses with a sole qualification.

All sole qualified RNs, with or without a notation, need to ensure that they have the appropriate education and experience to work in a different context of practice.

Definitions

Advanced practice is where nurses incorporate professional leadership, education, research and support of systems into their practice. Their practice includes relevant expertise, critical thinking, complex decision-making, autonomous practice and is effective and safe. They work within a generalist or specialist context, and they are responsible and accountable in managing people who have complex healthcare requirements.

Advanced practice in nursing is demonstrated by a level of practice and not by a job title or level of remuneration.

Advanced practice for the purpose of the nurse practitioner endorsement requires 5,000 hours clinically based advanced practice in the past six years.

Cosmetic injections are serious medical procedures that involve injecting a substance under the skin to change an aspect of appearance. For example, reducing the appearance of wrinkles or lines on the face, or putting filler into the lips to make them fuller. If used incorrectly, the substances in these injections could cause skin damage, blindness or even death (Therapeutic Goods Administration)⁵.

Cosmetic medical and surgical procedures are operations and other procedures that revise or change the appearance, colour, texture, structure or position of normal bodily features with the dominant purpose of achieving what the person perceives to be a more desirable appearance or boosting the persons self-esteem.

Major cosmetic medical and surgical procedures (‘cosmetic surgery’) involve cutting beneath the skin. Examples include breast augmentation, breast reduction, rhinoplasty, surgical face-lifts and liposuction.

Minor (non-surgical) cosmetic medical procedures (‘cosmetic medical procedures’) do not involve cutting beneath the skin but may involve piercing the skin. Examples include non-surgical cosmetic varicose vein treatment, laser skin treatments, use of CO2 lasers to cut the skin, mole removal for purposes of appearance, laser hair removal, dermabrasion, chemical peels, injections, micro-sclerotherapy and hair replacement therapy.

Nurse practitioner (NP) is a registered nurse endorsed as an NP by the NMBA. The NP practises at a clinical advanced level, meets and complies with the Nurse practitioner standards for practice, is able to practice independently and has direct clinical contact.

NPs practice collaboratively in multi-professional environments.

The NP practises within their scope under the legislatively protected title ‘nurse practitioner’ under the National Law.

Standards Australia and Standards New Zealand. (2018). Australian/New Zealand Standard 2018 ‘Guide to the safe use of lasers and intense light sources in health care (4173:2018) pp18
Australian Government, Therapeutic Goods Administration (January 2022) Advertising: when cosmetics are regulated as therapeutic goods
Jones, DHJ, Fitzgerald, R et al (2021) ‘Preventing and Treating Adverse Events of Injectable Fillers: Evidence-Based recommendations from the American Society for Dermatologic Surgery Multidisciplinary Task Force’ Dermatologic surgery, Vol47(2) 214-226
Nursing and Midwifery Board of Australia. (2015). Fact sheet: Enrolled nurse standards for practice
Australian Government, Therapeutic Goods Administration (August 2019) Cosmetic injections checklist